Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation in the subject line of e-mail.

Rabies in a Dog Imported from Iraq -- New Jersey, June 2008

Please note: An erratum has
been published for this article. To view the erratum, please click
here.

Rabies vaccination and stray dog control have led to successful control of canine rabies in the United States. The number
of rabid dogs reported decreased from approximately 5,000 in 1950 to 79 in 2006, when the canine rabies virus
variant associated with dog-to-dog rabies transmission was declared eliminated in the United States
(1). On June 18, 2008, a mixed-breed dog, recently shipped from Iraq into the United States, was confirmed to have rabies by the Public Health
and Environmental Laboratories of the New Jersey Department of Health and Senior Services. A total of 24 additional animals
in the shipment, all potentially exposed to the rabid dog, were distributed to 16 states. This report summarizes the
epidemiologic investigation by the New Jersey Department of Health and Senior Services, Bergen County Department of Health, and
CDC, and the ensuing public health response. These findings underscore the need for vigilance regarding rabies (and other
zoonotic diseases) during animal importation to prevent the possible reintroduction and sustained transmission of canine rabies in
U.S. dog populations.

Case Report

On June 5, 2008, a shipment of 24 dogs and two cats arrived in the United States from Iraq as part of an
international animal rescue operation. The goal of the operation was to reunite servicemen returning to the United States with animals
they had adopted in Iraq. Upon arrival at Newark Liberty International Airport, the animals received physical examinations
from volunteer licensed veterinarians. One cat became ill with neurologic signs during transport and was euthanized on arrival.
The cat was tested for rabies and was negative. The remaining 24 dogs and one cat were housed for several days at the
airport before distribution to their final U.S. destinations.

On June 8, one of the 24 dogs, a mixed-breed aged 11 months (dog A), became ill and was taken to a veterinarian the
next day. The dog was hospitalized with fever, diarrhea, wobbly gait, agitation, and crying. The dog's condition
deteriorated, progressing to lateral recumbency with periods of agitation. On June 11, the dog was euthanized. Specimens were shipped
to the Public Health and Environmental Laboratories for rabies testing, but delivery of the specimens was delayed. On June
18, the specimens were tested, and rabies was diagnosed. Specimens also were submitted to CDC, where rabies was confirmed
on June 26 and typed as a rabies virus variant associated with dogs in the Middle East.

Public Health Investigation

The potentially infectious period for a dog, cat, or ferret with rabies can begin as many as 10 days before the onset of
clinical signs and continue throughout the clinical course until death
(2). To identify potential rabies exposure to humans or
other animals while dog A was in Iraq, during transport, or at the airport shelter, an investigation was initiated by the New
Jersey Department of Health and Senior Services and the Bergen County Department of Health, with participation from CDC.
The dog was reportedly in the possession of a U.S. soldier in Baghdad for approximately 7 months before shipment to the
United States. The dog had been kept in an indoor-outdoor run on a military base and had not been vaccinated for rabies; the
owner reported no signs of illness in the dog or potential exposure to other rabid animals during the 7 months. The owner
also reported no potential exposures to other persons or animals during the 2 days of potential infectivity before the dog
was transferred to the animal rescue operation for shipment on May 31.

Upon arrival in the United States, none of the 24 dogs were accompanied by the valid rabies vaccination certificates required
for admission by CDC animal importation
regulations.* For dogs aged >3 months, a rabies vaccination must be administered
at least 30 days before the date of arrival at a U.S. port. Five of the 24 dogs (not including dog A) reportedly had received
a previous rabies vaccination; however, none of the information required for a valid rabies vaccination certificate was
available, including vaccine manufacturer, lot numbers, or a certifying veterinarian signature. Twenty-one of the animals in
the shipment, including dog A, had received a primary rabies vaccination in Iraq during May 28 -- 31, immediately before
being shipped to New Jersey. Because none of the dogs met rabies vaccination requirements for importation, in accordance with
the importation regulation, a confinement agreement was issued by CDC, stating where the animals would be held for at least
30 days after vaccination. During shipment and upon arrival in New Jersey, all the animals were housed in separate
crates; however, interviews with persons present during the animals' arrival and stay in Newark identified potential periods
during which dogs, including dog A, were allowed to intermingle.

On June 10, 1 day before dog A was euthanized and 8 days before rabies was diagnosed, the remaining 23 dogs and one
cat were shipped to destinations in 16
states. Because none of the surviving animals had a verifiable history of vaccination at
least 30 days before their potential exposure to dog A, CDC recommended immediate vaccination and a 6-month quarantine
for all of them (2). State health departments in the 16 states were advised of the recommendations.

During the public health investigation, 28 persons were evaluated for potential rabies exposure; 13 were identified
with potential exposure because of direct contact with possibly infectious saliva
(3) and were recommended to initiate rabies postexposure prophylaxis (PEP). All 23 dogs and one cat were located by state and local health authorities within 2 weeks
of the rabies diagnosis. No clinical signs consistent with rabies were reported in the animals during 20 days of follow-up. All
24 animals continue to be monitored during the 6-month quarantine period.

Editorial Note:

Rabies virus infection results in a fatal encephalomyelitis in humans and other mammals. Globally, the
most common sources of human rabies are geographically distinct rabies virus variants maintained predominantly through
dog-to-dog transmission (i.e., canine rabies), but sometimes with
spillover§ into other species. In the United States,
occasional spillover into dogs of rabies virus variants associated with wildlife has occurred. However, since 2004, no rabies
case attributable to an indigenously acquired canine rabies virus variant has been reported
(1).

Canine rabies virus variants most commonly are imported via unvaccinated dogs from areas where rabies is enzootic, such
as Asia, Africa, the Middle East, and parts of Latin America, where canine variants are responsible for most of the 55,000
human rabies deaths estimated worldwide each year
(4). In May 2004, an unvaccinated puppy was flown from Puerto Rico
to Massachusetts as part of an animal rescue program. The day after arrival, the puppy exhibited neurologic signs,
was euthanized, and was subsequently confirmed to have rabies. Six persons were recommended to receive PEP because
of potential exposure. In June 2004, an unvaccinated puppy adopted by a U.S. resident in Thailand was confirmed to have
rabies by the California Department of Public Health. Of 40 persons interviewed for potential rabies exposure, 12 received PEP.
In March 2007, a puppy adopted by a U.S. veterinarian while volunteering in India was confirmed to have rabies by the
Alaska Department of Health and Social Services. The puppy was flown in cargo to Seattle, Washington, then adopted by
another veterinarian in Juneau, Alaska, where it was flown 7 days after arrival. Of 20 persons interviewed for potential rabies
exposure,
eight received PEP (5,6). In all three cases, the rabies virus variant was typed as a variant circulating in dogs and
terrestrial wildlife in the animal's country of origin (i.e., mongoose and canine rabies virus variants enzootic in Puerto Rico,
Thailand, and India, respectively).

This report reiterates the need for education of the public regarding rabies incidence in other countries and preventing
rabies exposure. While traveling in areas that are endemic for
rabies, travelers should not pet stray animals. In addition, travelers
should not adopt stray animals without acquiring a veterinarian's health assessment and ensuring proper animal vaccination for
importation. Travelers also should consider their potential for rabies exposure from animals, understand proper wound management,
and promptly report animal bites to health-care providers
(7). Health information for travelers is available at
http://wwwn.cdc.gov/travel/contentyellowbook.aspx.

CDC administers federal importation regulations for dogs. These regulations allow admittance of unvaccinated dogs
aged <3 months, provided the importer signs an agreement to vaccinate the dog at age 3 months and confine the animal for 30
days after the vaccination. Dogs aged >3 months that have not been vaccinated for rabies also must be confined until
vaccinated and for 3 months after vaccination. Upon arrival in the United States, importers should declare animals to federal
authorities and comply with those requirements for confinement of unvaccinated puppies.

CDC's regulations were created in the early 1950s to guide persons importing dogs or cats as their personal pets.
However, recent trends in dog importations have shown an increase in the numbers of animals being imported for commercial pet
trade (8). CDC is working to update current regulations and better address the importation of dogs. In July 2007, the
U.S. Department of Health and Human Services posted an advance notice of proposed rulemaking to begin the process of
revising CDC's animal importation regulations, including those that apply to dogs and other companion
animals.¶

U.S. animal importation regulations, rabies vaccination requirements for dogs, wildlife rabies surveillance and
vaccination programs, and prophylaxis for human exposures all contribute to public health protection from rabies. Continued
vigilance and partnership between federal and state agencies, as well as health professionals and pet importers, are vital to decrease
the risk for reemergence of canine rabies virus in the United States.

The findings in this report are based, in part, on contributions by J Bateman, A Plummer, MD, H Gunness, Newark Quarantine Station,
S Shapiro, MHA, New York City Quarantine Station, Div of Global Migration and Quarantine, National Center for Preparedness, Detection,
and Control of Infectious Diseases; T Cieslak, MD, Coordinating Office for Terrorism Preparedness and Emergency Response; and P Yager and
I Kuzmin, MD, Div of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC.

World Health Organization. WHO expert consultation on rabies. First report. WHO technical report series: no. 931. Geneva, Switzerland:
World Health Organization; 2004. Available at
http://www.who.int/rabies/trs931_%2006_05.pdf.

McQuiston JH, Wilson T, Harris S. Importation of dogs into the United States: risks from rabies and other zoonotic diseases. Zoonoses and
Public Health 2008;55:421 -- 6.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of
Health and Human Services.References to non-CDC sites on the Internet are
provided as a service to MMWR readers and do not constitute or imply
endorsement of these organizations or their programs by CDC or the U.S.
Department of Health and Human Services. CDC is not responsible for the content
of pages found at these sites. URL addresses listed in MMWR were current as of
the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents.
This conversion might result in character translation or format errors in the HTML version.
Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr)
and/or the original MMWR paper copy for printable versions of official text, figures, and tables.
An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S.
Government Printing Office (GPO), Washington, DC 20402-9371;
telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to
mmwrq@cdc.gov.